Raf

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symtoms

Please select which of the images below best represents your hair loss.

A
B
C
D
E
Other/no pattern fits well

Did your hair loss occur suddenly?

Yes No

Are you experiencing any inflammation on your scalp?

Yes No

When did you first notice any hair loss?

In the last month
More than a month ago

Health

Do you have a history of depression or generalized anxiety disorder?

Yes No

Are you allergic to Propecia (Finasteride)?

Yes No

Are you already taking finasteride, Propecia or Proscar for a condition other than hair loss?

Yes No

Have you ever been diagnosed with prostate disease or male breast cancer?

Yes No

Could your hair loss be explained by any illness or medication you are currently taking?

e.g. Cytotoxic drugs used in chemotherapy are causing your hair loss
e.g. Dietary problem causing your hair loss

Yes No

Have you been diagnosed with Androgenic Alopecia (Male Pattern Baldness)?

Yes No

Do you have any conditions affecting your liver, kidneys, prostate or urinary system?

Yes No

Do you have any difficulties getting or keeping an erection when you want one?

Yes No

Medication

Do you understand that regrowth of hair can take up to 6 months?

Yes No

Are you currently taking any medication, or have you recently finished a course of medication?

Yes No

Are you currently taking Finasteride 1mg tablets (Propecia)?

Yes No

Agreement

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Medical Assesment Hair Loss